Section/division Accident and Incident Investigations Division Form Number: CA 12-57

LIMITED SERIOUS INCIDENT INVESTIGATION

Reference CA18/2/3/1396
Number
Classification Serious Date 13 April 2022 Time 1538Z
Incident
Type of Training (Part 141)
Operation
Location

Place of Departure Wonderboom Aerodrome Place of Intended Landing Wonderboom Aerodrome

(FAWB), Gauteng Province (FAWB), Gauteng Province
Place of Incident Wonderboom Aerodrome (FAWB) on the apron outside the operator’s hangar

GPS Co-ordinates Latitude 25˚39’.00” S Longitude 028˚13’.00” E Elevation 4095 feet

Aircraft Information

Registration ZS-SCE

Model/Make Cessna 172M (Serial Number: 17263043)

Damage to Aircraft Substantial Total Aircraft Hours 3536.2

Pilot-in-command

Licence Type Commercial Pilot Gender Male Age: 23

Licence (CPL)
Licence Valid Yes

Total Hours on 600 Total Flying Hours 1209.2

Type
People 2+0 Injuries 0 Fatalities 0 Other (on 0
On-board ground)
What Happened

On 13 April 2022, a Cessna 172M aircraft with registration ZS-SCE, operated by Eagle Air Flying
School, was scheduled for a night flight training when the incident occurred at Wonderboom
Aerodrome, Gauteng province. On-board the aircraft were the instructor and the student pilot. The
flight was intended to be conducted under the provisions of Part 141 of the Civil Aviation
Regulations (CAR) 2011 as amended.

The instructor and the student pilot pulled out the aircraft from the operator’s hangar and onto the
apron to conduct pre-flight inspections and start-up procedures. The aircraft was cranked several
times during start-up and, later, a bystander who was a distant away from the aircraft observed
smoke emanating from the bottom of the engine compartment, followed by flames after engine-
start. Thereafter, the bystander ran towards the aircraft, gesturing to the instructor and the student
pilot to get their attention to alert them of the smoke and the fire. After they had been alerted, the
instructor and the student pilot switched off the engine and disembarked the aircraft. Both were

SRP date: 16 August 2022 Publication date: 18 August 2022

unharmed. The fire extinguisher was used to extinguish the fire. The aircraft sustained fire damage
to the engine compartment.

According to https://www.boldmethod.com/learn-to-fly/aircraft, during a cold engine-start, you have

to prime the engine. When you prime an engine, you are putting fuel into the cylinders (or the
intake manifold) so that the engine can fire. Pilots tend to over-prime the engine by priming too
much or too many times (we're guilty of it too). In contrast, there are very few people who prime too
little.

Figure 1: The aircraft after the fire was put out. (Source: Pilot)

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 Figure 2: A close-up picture showing the black residue caused by the fire. (Source: Pilot)

What was found:

• The nose engine cowlings, spinner paint and landing light were damaged.

• The gaskets and plunger were damaged due to heat from the fire.

• The air-filter and the front baffle rubbers on the carb heat box were damaged.

• The carburettor was removed and inspected by the aircraft maintenance organisation
(AMO), and it was found undamaged.

• The aircraft’s maintenance records were up to date; they revealed that the aircraft was
maintained in accordance with (IAW) the manufacturer’s specifications and existing
procedures.

• The aircraft had a Certificate of Release to Service which was issued on 23 February 2022
with an expiry date of 23 February 2023 or at 7184.20 hours, whichever occurs first.

• The aircraft had a valid Certificate of Registration which was issued to the current owner on
29 July 2021.

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 • The aircraft was issued a Certificate of Airworthiness on 13 July 2015 with an expiry date of
31 July 2022.

• The aircraft had undergone a mandatory periodic inspection (MPI) on 23 February 2022 at
7084.20 airframe hours. It was flown a further 65.1 hours since the last MPI.

• The pilot was initially issued a Commercial Pilot Licence (CPL) on 2 April 2019 with an
expiry date of 31 July 2022. His Class I medical certificate was issued on 18 May 2021 with
an expiry date of 31 May 2022.

• The AMO had a valid AMO Certificate issued on 24 May 2021 with an expiry date of 31 May
2022.

• There were no defects recorded in the defect logs with either the navigational or
communication systems prior to the accident flight.

The information below is an extract from the Pilot’s Operating Handbook — Cessna 172:

Engine fire during start on ground

1) Cranking--Continue, to get a start which would suck the flames and accumulate fuel through the
carburettor and into the engine.

If the engine starts

2) Power--1700 RPM for a few minutes.

3) Engine--SHUTDOWN and inspect for damage.

If the engine fails to start

4) Throttle--FULL OPEN

5) Mixture--IDLE CUT-OFF

6) Cranking--CONTINUE for two or three minutes.

7) Fire Extinguisher--OBTAIN (have ground attendants to obtain if not installed).

8) Engine--SECURE.

a. Master Switch--OFF.
b. Ignition Switch—OFF
c. Fuel Shutoff Valve—OFF

9) Fire—EXTINGUISH using fire extinguisher, seat cushion, wool blanket, or dirt. If practical, try to
remove carburetor air filter if it is a blaze.

CA 12-57 Date: 18 June 2021 Page 4 of 6

10) Fire Damage—INSPECT, repair damage or replace damaged components or wiring before
conducting another flight.

After the incident, all damaged parts were replaced with new parts — the carb heat box baffle
rubbers were replaced, and the carb heat box was inspected to ensure it operated as expected;
the cowling and spinner were repaired and re-painted; the carburettor was re-installed with new
gaskets and the carb heat box was refitted with a new air filter; the aircraft was ground-run and all
systems were within the parameters.

Probable cause

The engine was over-primed during start-up, resulting in excess fuel catching fire and damaging
the engine compartment.

Safety Action/s

None.

Safety Message and/or Safety Recommendation/s

None.

Purpose of the Investigation

In terms of Regulation 12.03.1 of the Civil Aviation Regulations (CAR) 2011, this report was
compiled in the interest of the promotion of aviation safety and the reduction of the risk of aviation
accidents or incidents and not to apportion blame or liability.

About this Report

Decisions regarding whether to investigate, and the scope of an investigation are based on many
factors, including the level of safety benefit likely to be obtained from an investigation. For this
occurrence, no investigation has been conducted, and the Accident and Incident Investigations
Division (AIID) has relied on the information submitted by the affected person/s and organisation/s
to compile this brief report. The report has been compiled using information supplied in the initial
notification, as well as follow-up information to bring awareness of potential safety issues to the
industry in respect of this occurrence, as well as possible safety action/s that the industry might
want to consider in preventing a recurrence of a similar accident.

This report provides an opportunity to share safety message/s in the absence of an investigation.

All times given in this report are Co-ordinated Universal Time (UTC) and will be denoted by (Z).
South African Standard Time is UTC plus 2 hours.

Disclaimer

This report is produced without prejudice to the rights of the AIID, which are reserved.

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This report is issued by:

Accident and Incident Investigations Division

South African Civil Aviation Authority
Republic of South Africa

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